An ER case

1. CASE PRESENTATION
DR AMRITHA GEORGE

2.  A 26 year old female was brought to the ER in a
trolley with c/o fever since 7 days & one episode
of involuntary movements with uprolling of eyes &
frothing of mouth 3 hrs back.
 A – Airway – patent, no abnormal
sounds/secretions
 B – Breathing – 16/’ – regular
b/l chest rise equal
chest – AEBE, No added sounds
SPO2 – 95% in RA

3.  Circulation – PR – 68/’ ,regular
normal volume & character
no RF delay , all peripheral pulses
palpable bilaterally &
equally
BP – 130/800 mmHg in left arm in
supine position
 Disability – E3V4M6
pupils – 2 mm bilaterally
reacting to light
 Exposure – temperature – 98.6 df

4.  Allergies – no known food/drug allergies
 Medications – NIL
 Past medical history – NIL
 Last meal – 9 pm on day before
 LMP – June 1 2021

5. Events
 Patient was apparently normal till 3rd july when
she developed headache followed by fever
 She was taken to a local hospital where she
was given symptomatic management & her
covid antigen was tested negative.
 She was advised admission, but since she
was lactating, she went home.
 Next day she had fever & there were multiple
episodes of vomiting & loose stools

6.  She was taken to nearby tertiary care centre &
was admitted there for further evaluation.
 She was started on IV antibiotics & loose
stools subsided
 But vomiting persisted on taking solid foods
 An initial diagnosis of short febrile illness &
UTI was made due to the presence of 8-10
pus cells in URE.
 However urine culture was sterile

7.  Due to persisting fever & headache
neuromedicine consultation was done
 Provisional diagnosis of meningitis was made
& she was started on Inj Meropenem 2g IV
q8h.
 LP & CSF study was done on 9/7/21 which
showed 4 cells which were lymphocyte
predominant
 CSF protein & sugar was WNL

8.  Contrast MRI of brain was taken on the same
day & was reported as no significant
abnormality
 Dengue, Lepto & scrub typhus work up were
negative.
 She started having loose stools again on D7

9.  On D8 early morning she had involuntary jerky
movements, uprolling of eyes & frothing of
mouth
 She was given Inj Lorazepam 4mg IV STAT &
Inj Levipil 1 g IV STAT
 Bystanders wanted further treatment in AHRI &
was brought here

10. DIFFERENTIAL DIAGNOSIS
 Viral meningoencephalitis
 Fungal meningoencephalitis
 Autoimmune encephalitis

11. PHYSICAL EXAMINATION
 Drowsy
 Ill built & nourished
 No pallor/ icterus/ cyanosis/ clubbing/ edema/
lymphadenopathy

12.  Chest – AEBE, normal vesicular breath
sounds
no added sounds
 CVS – S1, S2 +, NO MURMURS
 P/A – soft, non-tender, no organomegaly
 CNS – E4V5M6, pupils 2 mm reacting to light

13. Investigations
 Hb – 8.2
 TC – 10,000
 RFT - WNL
 LFT – WNL
 BT & CT –
NORMAL
 PT – 12.4, INR – 0.9
 aPTT – 36.6
 THROAT/SKIN/AXIL
LA & GROIN SWAB
taken for culture
showed normal flora

14. MRI BRAIN & MR VENOGRAPHY
 Normal flow void of superior sagittal sinus &
right transverse sinus not visualised
 SWI blooming seen in corresponding area
 s/o venous sinus thrombosis
 Haemorrhagic venous infarct noted in the right
high parietal lobe with adjacent mild SAH

18. EVENTS IN THE HOSPITAL
 This 40 year old female brought to the ER with
c/o numbness of left upper & lower limb with
one episode of seizure & h/o OCP intake was
admitted in isolation ICU after COVID test
 Patient was stable at the time of admission
 MRI brain done showed venous sinus
thrombosis involving superior sagittal & right
transverse sinus with cortical vein thrombosis
in the right high parietal region
 Hemorrhagic venous infarct in right high
parietal lobe

19.  She was treated with 5000 IU of unfractionated
heparin as IV STAT dose & 1000 IU as infusion
at a rate of 5.5 ml/hr daily
 Anemia treated with iron supplementation
 To keep aPTT values at 2 times higher than
normal
 After treatment with heparin for 7 days , aPTT
levels elevated
 Therefore bridged with warfarin with PT- INR
monitoring
 Thrombosis panel awaited

20. CORTICAL VEIN
THROMBOSIS

21. ETIOLOGIES
 INFECTION
 PREGNANCY(8)
 PEURPERIUM
 OCP
 DEHYDRATION
 CACHEXIA(MARANTI
C)
 CHF
 ULCERATIVE
COLITIS
 SICKLE CELL
 PROTIEN C &S DEF
 LEIDEN 5
 ANTI THROMBIN 3
 APLA
 PNH
 HOMOCYSTEINURIA
 BECHET
SYNDROME
 LP(VR506Q)
 TRAUMA
 MALIGNANCY

22. INVESTIGATION
 CT
 MRI
 MR VENOGRAPHY

23. INVESTIGATION
PROTIEN C&S
APLA- ANTICARDIOLIPIN,LU[US COAGULANT
FACTOR 2
HOMOCYSTEINE
PNH PANNEL
LEUKOCYTE ALP
USG HEAD (SSS THROMBOSIS IN NEONATE)

24. Rx
 Rx THE CAUSE
 HEPARIN
 AVOID STEROIDS
 CONTROL HYPERTENSION
 ICP MONITORING
 GOOD HYDRATION WITH ISOTONIC
SALINE
 LOOP DIURETICS